Continent cutaneous urinary diversion: long-term follow-up of more than 800 patients with ileocecal reservoirs

[Follow-up after urinary diversion]

Radical cystectomy is currently the standard of care for muscle-invasive bladder cancer. Different parts of the small and large intestines can be utilized for continent and incontinent urinary diversion. The postoperative follow-up after urinary diversion should consider functional, metabolic and oncological aspects. The functional follow-up of (continent) urinary diversion includes stenosis, emptying disorders or incontinence. The oncological follow-up should focus on the detection of local, urethral and upper tract recurrences as well as distant metastases. As 90% of the tumor recurrences occur during the first 3 years, a close follow-up should be carried out during this period. Metabolic disturbances, such as vitamin B12 and bile acid deficits, acidosis and disorders of calcium metabolism can also occur during long-term follow-up. The metabolic follow-up should consider the metabolic consequences of the parts of the intestines utilized for the urinary diversion.

Analysis of early perioperative outcomes of robot-assisted radical cystectomy and colonic diversion

Studies of right colon pouch urinary diversion have widely varying estimates of the risk of perioperative complications, reoperation, and readmission. We sought to describe the association between specific risk factors and complication, readmission, and reoperation rates following right colon pouch urinary diversion. Patients undergoing robot-assisted right colon pouch urinary diversion from July 2013 to December 2022 were analyzed. Outcome measures include high-grade (Clavien-Dindo grade ≥ 3) complications within 90 days, readmission within 90 days, and reoperation at any time during follow-up. Specific risk factors such as age, gender, body mass index (BMI), diabetes, Charlson comorbidity index (CCI), and prior radiation were analyzed to establish an association with these outcomes. During the study period, 77 patients underwent the procedure and were eligible to study. The average follow-up was 88.7 (SD 14) months. 90-day high-grade complications were 24.67%, and 90-day readmission was 33.76%. The cumulative rate of any reoperation was 40.2%, and major reoperation was 24.67%. Female gender (OR 3.3, p = 0.015), 1 kg/m2 increase in BMI (OR 3.77, p = 0.014), diabetes (OR 3.49, p = 0.021), higher CCI (OR 1.59, p = 0.034), prior radiation (OR 1.97, p = 0.026), lower eGFR (OR 0.99, p = 0.032) and BMI ≥ 25 kg/m2  (OR 3.9, p value 0.02) was associated with Clavien III-IV complications. Female gender (OR 3.3, p = 0.015), diabetes (OR 3.97, p = 0.029), higher Charlson Comorbidity Index (OR 1.73, p = 0.031), prior radiation (OR 1.45, p = 0.029), lower eGFR (OR 0.87, p = 0.037) and BMI ≥ 25 kg/m2 (OR 3.86, p = 0.031) were predictive of reoperation. Overall, the rate of postoperative complications, readmissions, and reoperation was high but consistent with other studies. This study helps further characterize surgical outcomes after right colon pouch urinary diversion and highlights patients who may benefit from enhanced preoperative management for minimising complications.

Continent cutaneous diversion: Unveiling the interplay of neuro-urology and oncological challenges

OBJECTIVES

The objective of our study is to demonstrate the practical application of continent cutaneous urinary diversion (CCUD) in oncological patients, with a focus on various aspects of the procedure: surgical challenges, functional outcomes, and quality of life.

MATERIALS AND METHODS

We studied the perioperative and follow-up data of patients who underwent cystectomy for cancer associated with CCUD (Mitrofanoff, Monti or Casale). We retrospectively analyzed complications within 30days and beyond 30days post-surgery. We evaluated oncological outcomes. Patients' quality of life was assessed using the Bladder Cancer Index (BCI) questionnaire. Results are given on an intention-to-treat basis.

RESULTS

A total of 24 patients were included in the study (July 2001 and May 2022), with a median follow-up of 62.5months. We report three deaths due to neoplasic recurrence. Forty-six percent had an early postoperative complication, two of whom required revision surgery. Overall, the medium-term complication rate was 70% and the reoperation rate was 62%. There were 8 stomal cutaneous stenoses (33%) and 3 uretero-ileal stenoses (12.5%). Overall satisfaction was rated at 9.2/10 on average, and body image was unaltered or slightly altered in 62.5% of patients. Of the patients who responded to the BCI, 75% had complete continence.

DISCUSSION

The experience gained with continent stomas in neuro-urology has allowed, in carefully selected cases, to offer patients an alternative that can improve their quality of life in a context already burdened by the shadow of cancer. CCUD can be proposed as an alternative to Bricker diversion in cases of urethral invasion or a high risk of neobladder incontinence, in selected patients.

LEVEL OF EVIDENCE: 4

Troubleshooting of failed continence mechanisms in the ileocecal pouch: Operative technique and long-term results of the intussuscepted ileal nipple valve

OBJECTIVES

To provide a detailed step-by-step operative technique, and to report on long-term functional and metabolic outcomes in secondary continence mechanisms in the form of secondary intussuscepted ileal nipple valves in revisional surgery of ileocecal pouches.

METHODS

From May 1997 to May 2015, 18 female and 10 male patients suffering from dysfunctional primary continence mechanisms of their ileocecal pouch underwent revisonal surgery to create a secondary ileal nipple valve at our tertiary referral center. The average follow-up period was 65.4 months.

RESULTS

After surgery, 24 patients were continent by day and night, and four patients showed minor incontinence with the use of a safety pad. The average frequency of clean intermittent catheterization decreased both during the day and at night. The diameter of the catheters used for clean intermittent catheterization increased significantly. No patient showed stomal stenosis, change of stool habits or metabolic situation in the follow-up period. Furthermore, the creation of the secondary ileal nipple valves did not affect the capacity of the reservoir. In the long-term follow up, two patients required the construction of a third continence mechanism, making for an overall success rate of 92% in the study group.

CONCLUSION

To our knowledge, this is the first study of long-term results after the creation of secondary ileal nipple valves. We provide evidence that the creation of a secondary ileal nipple valve is a safe and reliable procedure for continence restoration in ileocecal pouches with excellent functional and metabolic long-term outcomes.

[Urinary diversion after uro-oncologic interventions in women: the right procedure for the right patient]

Bladder carcinoma is a relatively rare tumour in women. The even rarer constellation of an invasive carcinoma or a high-risk situation when cystectomy is indicated requires adequate urinary diversion.The individual underlying circumstances of tumour and patient and the experience and preferences of the surgeon determine the choice of urinary diversion.A variety of alternatives are available for bladder replacement. The first decision to be made is between incontinent or continent urinary diversion. There is no general solution that fits all patients, but an individual solution must be found based on adequate information. Options include incontinent drainage with an ostomy, e. g. ureterocutaneostomy or ileum conduit, and the much more complex techniques of the continent variants of orthotopic or heterotopic replacement.Experience with continent diversion is significantly limited in women compared with men. In particular, the orthotopic connection to the urethra reveals gender-specific differences.All in all, clear inclusion or exclusion criteria for the different techniques have to be respected. Especially in cases when quality of life or body image play a crucial role, it is difficult to decide which type of urinary diversion is appropriate. This requires extensive experience on the part of the surgeon regarding the various options of surgical methods as well as knowledge and control of consecutive complications.

Smart Implantable Artificial Bladder: An Integrated Design for Organ Replacement

Substituting the natural bladder with an artificial solution, after cancer and other pathologies, is an ambitious challenge in biomedical engineering. In this work we propose a fully implantable smart artificial bladder system (ABS) that collects urinary fluids and provides the subject with real-time feedback on the implant status. To achieve long term duration, the ABS was designed to be unstretchable in order to be treated with urine resistant coatings and included built-in passive check valves preventing reflux to kidneys. To estimate the amount of fluid collected, the ABS was provided with four electromagnetic distance sensing units and a control unit. An algorithm implemented on an embedded controller enabled the reconstruction of the bladder volume through sensors readings. A wireless data transfer system allows for providing a real-time feedback to the subject. Bench tests validated volume reconstruction accuracy and ex-vivo experiments verified the implantability of the proposed device on a human cadaver, proving the reliability of a Bluetooth data transmission system and paving the way towards an in-body/out-body communication. The proposed solution has the potential to overcome the limitations of currently available replacement strategies towards a new generation of implantable devices for lost organ functions replacement.

Long-term Outcomes of Cystectomy and Crossfolded Ileal Reservoir Combined with an Afferent Tubular Segment for Heterotopic Continent Urinary Diversion: A Longitudinal Single-centre Study

BACKGROUND

The crossfolded ileal reservoir combined with an afferent tubular isoperistaltic segment for heterotopic continent urinary diversion has been performed on a regular basis for over 20 years. Yet data on long-term-outcomes remain sparse.

OBJECTIVE

To report long-term functional and oncological outcomes, gastrointestinal and metabolic disturbances, urinary tract infections (UTIs), and quality of life.

DESIGN, SETTING, AND PARTICIPANTS

Long-term functional and oncological outcomes of a consecutive series of 118 patients undergoing cystectomy and construction of a continent cutaneous crossfolded ileal reservoir from 2000 to 2018 were evaluated.

INTERVENTION

Patients underwent cystectomy and construction of a continent cutaneous crossfolded ileal reservoir according to the Studer technique for bladder reconstruction.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Pre- and postoperative data until last follow-up appointment were entered prospectively in the departmental database. Self-reported questionnaires regarding quality of life, patient satisfaction, and difficulty in catheterisation were sent to patients preoperatively; after 3, 6, 12, and 24 mo; and at last follow-up, and were then manually entered in the departmental database.

RESULTS AND LIMITATIONS

The median follow-up was 7.8 (interquartile range 3-12.7) yr. Patient satisfaction was high in 77.4% and moderate in 16.9%. Serum creatinine and estimated glomerular filtration rate remained stable during follow-up. Of all patients, 81% (96/118) had at least one UTI during follow-up. Recurrent UTIs occurred in 67% (79/118) of patients. Urolithiasis was found in 12% (14/118), with 6% (7/118) having a single and 6% a recurrent event. Of all stone formers, 79% (11/14) had recurrent UTIs. In oncological patients, 12.5% (10/79) developed a local recurrence. Cancer-specific survival and overall survival were 90% and 88%, and 68% and 56% after 1 and 10 yr, respectively. A limitations is the retrospective analysis from prospectively assessed data.

CONCLUSIONS

A high satisfaction level, stability of kidney function, and low rates of urolithiasis in patients with a heterotopic continent ileal reservoir can be achieved, provided that close attention is paid to intra- and postoperative details. Regular lifelong follow-up is essential for timely detection and treatment of complications. Oncological outcome is not affected by the urinary diversion.

PATIENT SUMMARY

In patients with a continent cutaneous ileal reservoir, good quality of life and a high satisfaction rate are possible provided that patients adhere to regular lifelong follow-up.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines

CONTEXT

This overview presents the updated European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).

OBJECTIVE

To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the MMIBC guideline has been performed annually since its 2017 publication (based on the 2016 guideline). Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries, resulting in yearly guideline updates. A level of evidence and a grade of recommendation were assigned. Additionally, the results of a collaborative multistakeholder consensus project on advanced bladder cancer (BC) have been incorporated in the 2020 guidelines, addressing those areas where it is unlikely that prospective comparative studies will be conducted.

EVIDENCE SYNTHESIS

Variant histologies are increasingly reported in invasive BC and are relevant for treatment and prognosis. Staging is preferably done with (enhanced) computerised tomography scanning. Treatment decisions are still largely based on clinical factors. Radical cystectomy (RC) with lymph node dissection remains the recommended treatment in highest-risk non-muscle-invasive and muscle-invasive nonmetastatic BC, preceded by cisplatin-based neoadjuvant chemotherapy (NAC) for invasive tumours in "fit" patients. Selected men and women benefit from sexuality sparing RC, although this is not recommended as standard therapy. Open and robotic RC show comparable outcomes, provided the procedure is performed in experienced centres. For open RC 10, the minimum selected case load is 10 procedures per year. If bladder preservation is considered, chemoradiation is an alternative in well-selected patients without carcinoma in situ and after maximal resection. Adjuvant chemotherapy should be considered if no NAC was given. Perioperative immunotherapy can be offered in clinical trial setting. For fit metastatic patients, cisplatin-based chemotherapy remains the first choice. In cisplatin-ineligible patients, immunotherapy in Programmed Death Ligand 1 (PD-L1)-positive patients or carboplatin in PD-L1-negative patients is recommended. For second-line treatment in metastatic disease, pembrolizumab is recommended. Postchemotherapy surgery may prolong survival in responders. Quality of life should be monitored in all phases of treatment and follow-up. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/.

CONCLUSIONS

This summary of the 2020 EAU MMIBC guideline provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology Muscle-invasive and Metastatic Bladder Cancer (MMIBC) Panel has released an updated version of their guideline, which contains information on histology, staging, prognostic factors, and treatment of MMIBC. The recommendations are based on the current literature (until the end of 2019), with emphasis on high-level data from randomised clinical trials and meta-analyses and on the findings of an international consensus meeting. Surgical removal of the bladder and bladder preservation are discussed, as well as the use of chemotherapy and immunotherapy in localised and metastatic disease.

Retz* M, Rödel C, E. Gschwend J. The Diagnosis and Treatment of Patients With Bladder Carcinoma

BACKGROUND

In Germany, bladder carcinoma accounts for 3-4 % of all malignant tumors. New study findings in the fields of endoscopy, surgery, and systemic therapy have led to multimodal treatment approaches for bladder cancer that can prolong overall survival and improve the affected patients' quality of life.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, with special attention to the German Clinical Practice Guideline on the Early Detection, Diagnosis, Treatment, and Continuing Care of Bladder Carcinoma, along with data available on the websites of the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA). The bladder carcinoma guideline of the Onkopedia guidelines program was used as well.

RESULTS

75% of all urothelial carcinomas are diagnosed in the non-muscle-invasive stage. These carcinomas should be resected via the endoscopic transurethral approach whenever possible. Next, depending on the patient's risk profile, intravesical therapy may be needed. Patients with carcinoma in the muscle-invasive stage should be given multimodal treatment, including radical cystectomy with urinary diversion and perioperative systemic therapy; alternatively, bladder-preserving chemoradiotherapy can be offered in selected cases. For patients with metastatic bladder carcinoma, immunotherapy with checkpoint inhibitors has become well established for first- and second-line therapy alongside classic cytostatic treatment and has been shown to prolong patients' lives significantly. The administration of checkpoint inhibitors can prolong the overall survival of patients with metastases to 15-17 months.

CONCLUSION

The treatment of bladder carcinoma in all stages calls for interdisciplinary collaboration to ensure the provision of effective, individual multimodal treatment.

[Devastated bladder outlet-suprapubic catheter vs. reconstruction]

The combination of a severe urethral sphincter defect with simultaneous development of recurrent bladder outlet obstruction characterizes a "devastated bladder outlet", which often is not surgically reconstructable. Clinically, quality of life is considerably compromised in affected patients with a wide variance of symptoms, mostly complete incontinence, but also urinary retention. This condition is usually preceded by multiple endoscopic interventions or even open surgical procedures, occasionally also in combination with radiotherapy of the pelvic region as part of multimodal oncological therapy. Treatment of these cases is complex and limited to few promising procedures. A potential therapy should primarily include the decision about the possibility of preserving the urinary bladder. In individual cases, this can result in simple therapy options while at the same time maintaining an acceptable quality of life for those affected. If there is no possibility of a refunctionalization of the original bladder, supravesical urinary diversion is indicated as a last-resort therapy. This paper provides a review as well as the limits and possibilities of conservative and surgical treatment options for a devastated bladder outlet.

Current Indications and Techniques for the Use of Bowel Segments in Pediatric Urinary Tract Reconstruction

Today, there are few indications for the use of bowel in pediatric urology. This is in large extent due to the successful conservative therapy in patients with neurogenic bladder and the improved success of primary reconstruction in patients with the bladder exstrophy-epispadias complex. Only after the failure of the maximum of conservative therapy or after failure of primary reconstruction, bladder augmentation, or urinary diversion should be considered. Malignant tumors of the lower urinary tract (e.g., rhabdomyosarcomas of the bladder/prostate) are other rare indications for urinary diversion. Replacement or reconstruction of the ureter with a bowel segment is also a quite rarely performed procedure. In this review, the advantages and disadvantages of the different options for the use of bowel segments for bladder augmentation, bladder substitution, urinary diversion, or ureter replacement during childhood and adolescence are discussed.

An improved ileal conduit surgery for bladder cancer with fewer complications

BACKGROUND

Radical cystectomy and urinary diversion remains the standard surgical treatment for patients with muscle-invasive or high-risk or recurrent non-muscle-invasive bladder cancer. Although this approach prolongs patient survival remarkably, there are postoperative complications associated with urinary diversion. This study aimed to assess the efficacy of modified ileal conduit surgery for reducing early and late stoma- and ureteroileal anastomosis-related complications, as compared with conventional ileal conduit urinary diversion.

METHODS

We retrospectively evaluated the clinical data of bladder cancer patients treated with radical cystectomy and ileal conduit urinary diversion at Sun Yat-sen University Cancer Center between January 1, 2000 and June 30, 2016. Ileal conduit was created by the conventional or a modified technique. The clinicopathologic features of the conventional and the modified ileal conduit groups were compared using the t test and the Chi square test. Multivariable logistic regression analysis and multivariable Cox regression analysis were performed to determine the odds of developing stoma- and ureteroileal anastomosis-related complications in the two groups.

RESULTS

145 and 100 patients underwent the modified and conventional ileal conduit surgery, respectively. The two groups were comparable with regard to clinicopathologic features. The rate of stoma-related complications was significantly lower in the modified ileal conduit group than in the conventional ileal conduit group (0.7% vs. 17.0%, P < 0.001). No late stoma-related complications were seen in the modified ileal conduit group, but were seen in 13 (13.0%) patients in the conventional ileal conduit group. The rate of ureteroileal anastomosis-related complications was significantly lower in the modified ileal conduit group than in the conventional ileal conduit group (4.8% vs. 15.0%, P = 0.001). In multivariable analyses, the modified ileal conduit group was significantly less likely to develop stoma- (odds ratio [OR] = 0.024, 95% confidence interval [CI] 0.003-0.235; P = 0.001) or ureteroileal anastomosis-related complications (OR = 0.141, 95% CI 0.042-0.476; P = 0.002) than the conventional ileal conduit group.

CONCLUSIONS

Our modified surgical technique for ileal conduit urinary diversion may be effective for reducing early and late complications related to the stoma and the ureteroileal anastomosis. Prospective randomized clinical trials are needed to confirm our results.

Outcomes of right colon continent urinary pouch using standardized reporting methods

AIMS

Studies of right colon pouch urinary diversion estimate risk of perioperative complications, 1%-50%, and reoperation, 1%-69%. This wide range is due to variable outcome measurements and reporting methods; it is also unclear which factors increase the risk of complications and reoperation. We sought to characterize the impact of patient-specific factors on risk of complications, readmission, and reoperation after right colon pouch urinary diversion.

METHODS

Patients undergoing right colon pouch urinary diversion from January 2010 to April 2017 were analyzed. Outcomes included: high-grade complications within 90 days (Clavien-Dindo grade ≥3), readmission within 90 days, and reoperation at any time during follow-up. Patient-specific factors were analyzed to establish any associations with these outcomes.

RESULTS

During the study period, 53 patients underwent the procedure and the average follow-up was 30 (standard deviation [SD] 21.5) months; 90-day high-grade complications were 22% and readmission was 45%. The cumulative rate of any reoperation was 53% and major reoperation was 32%. Diabetes was associated with an increased risk of both postoperative complications and reoperation. Larger body mass index and prior abdominal surgery were associated with increased risk of readmission.

CONCLUSIONS

Overall the rate of postoperative complications, readmissions, and reoperation was high, but in agreement with other contemporary series. This study helps to further characterize surgical outcomes after right colon pouch urinary diversion, however, similar to other studies in the literature, the rarity of the procedure limits the power to establish a link between preoperative patient factors and outcomes.

Serous-lined, stapled pouch wall plication: initial results of a simple and quick novel continence mechanism in troubleshooting secondary to continent cutaneous urinary diversion

OBJECTIVES

To report a novel and straightforward technique of a secondary continent outlet for continent cutaneous urinary diversion (CCUD) reservoirs without the need for further bowel resection, reducing operating time and length of hospitalization.

PATIENTS AND METHODS

From 2015 to 2017, six patients with unreconstructable, incontinent outlets (out of a total pool of 595 patients with CCUD) have undergone the technique described in the present paper at our department. The technique relies on the Mitrofanoff principle, using a stapled full-thickness pouch wall plication, which creates a flap-valve continence mechanism.

RESULTS

All patients enjoyed full continence with ease of clean intermittent catheterization (CIC) in the postoperative period and on follow-up to a mean (range) of 12.4 (7-18) months. No major complications were encountered in any patient and the average capacity of the reservoirs was not compromised by the procedure (540 mL preoperatively vs 500 mL in further follow-up).

CONCLUSION

In revisional surgery for secondary CCUD incontinence, especially if the patient has already lost a significant amount of bowel or has previously undergone radiation therapy, the technique described here represents a safe and effective alternative to restore continence.

Spontaneous rupture of continent cutaneous urinary diversion after 25 years

Spontaneous rupture of a continent cutaneous urinary diversion is uncommon and diagnosis of this situation requires a high degree of suspicion. In this paper we present a 66-year-old man with continent cutaneous pouch after radical cystoprostatectomy that presented with spontaneous perforation 25 years after surgery. Spontaneous pouch perforation in our case after 25 years emphasizes the need for long follow-up in patients with continent diversion.

Long-term third-party assessment of results after continent cutaneous diversion with Lundiana pouch

OBJECTIVES

To investigate the long-term functional outcomes and complications after continent cutaneous diversion with the Lundiana pouch.

PATIENTS AND METHODS

Complications, re-operations, renal function, and continence were ascertained from patient charts. Outcome variables were validated by a second and independent review of the patient files.

RESULTS

A complication of Clavien-Dindo grade ≥III, including unscheduled re-admissions, occurred in 45/193 patients (23%) at ≤90 days of surgery. At a median follow-up of 13 years, 105/193 patients (54%) had undergone at least one re-operation, with uretero-intestinal stricture being the most prevalent cause [28 patients (15%)]. Re-operations were more prevalent in patients operated during the first half of the study period than during the second half (2000-2007; 62% vs 47%; P = 0.03), and they were also more frequent in patients who underwent surgery for benign causes than in patients who underwent surgery for malignancy (60% vs 51%; P = 0.04). Continence was achieved in 172/188 patients (91%). In all, 16% of all patients required revisional surgery of the outlet to remain continent with an easily catheterisable pouch or to address stomal stenosis. The mean decrease in estimated glomerular filtration rate was more pronounced in patients with benign indications for urinary diversion than in those with malignancies, even after adjusting for younger age at surgery and longer follow-up in the former group (22 vs 11 mL/min/1.73 m² ; P < 0.006). A disinterested third-party assessment revealed 10 postoperative complications, 17 re-operations during follow-up, and seven occasions of hospitalisation due to pyelonephritis (included in data above) not recorded at the primary data review.

CONCLUSIONS

The Lundiana pouch is associated with a high risk of re-operation, although the functional results are good. Independent review by a third party increased the validity of the outcome data.

W-pouch With Modified Non-isolated Extra Limb for Continence in Cutaneous Diversion After Radical Cystectomy

OBJECTIVE

To report the functional results of continent cutaneous ileal urinary diversion using modified W-pouch with non-isolated extra limb for continence.

PATIENTS AND METHODS

From January 2013 to January 2016, 21 patients with muscle-invasive bladder cancer with median (interquartile range) of 59 (56.5-62.5) years old underwent radical cystectomy with pelvic lymphadenectomy; they then had an ileal continent cutaneous pouch constructed from W-pouch with non-isolated extra limb for continence. The technique entails the creation of a detubularized ileal W-pouch with extra limb fashioned from 59 cm of the terminal ileum. This extra limb is not isolated from the pouch. The proximal part of this limb is tailored and fixed in a subserous extramural tunnel for continence, whereas the distal part is left continuous with the pouch. The median (interquartile range) of follow up was 12 (8-17) months. Evaluation of the technique included operative time, continence efficiency, overall complications, and quality of life questionnaire for the patients.

RESULTS

The median (interquartile range) of operative time of the operation was 4.7 (3.9-5.4) hours. The median (interquartile range) of operative time of the cutaneous pouch creation was 39 (33-43) minutes. No perioperative mortality had occurred. The incidence of continence was 95.2%. The overall complications were 42.8%, and most of them were grade 1 or 2 on Clavien-Dindo classification system.

CONCLUSION

Modification of W-pouch with non-isolated extra limb as continent cutaneous pouch can simplify the technique and shorten the operative time with efficient continence, less side effects, and good quality of life.

Technique of Suprafascial Anastomosis With Reduced Risk of Stenosis of the Efferent Outlet in Continent Catheterizable Urinary Diversion

OBJECTIVE

To describe our technique and long-term experience with a technique of a suprafascial anastomosis for the efferent continent segment in continent cutaneous urinary diversion, which aims to reduce the rate of stomal strictures.

MATERIALS AND METHODS

Between 1998 and 2013, up to 191 patients underwent continent cutaneous urinary diversion with a suprafascial anastomosis technique at our institution. A complete follow-up was achievable in 82 patients. The retrospective analysis included continence rates, stomal complications, and other complications related to the urinary diversion such as anastomotic insufficiencies, fistulas, or hernias.

RESULTS

The study population consisted of 82 patients with 67 (82%) women and 15 (18%) men with a median age of 58 years. The median length of follow-up was 82 months (range 13-203) with a median survival time of 46 (range 13-193) months. At the time of the analysis, 46 patients (57%) were still alive. Five out of 82 patients (6%) presented with a relevant stenosis in umbilical stoma that required surgical revisions. Nine patients (12%) with functional stenosis could be treated conservatively. Continence was achieved in 74 of 82 patients (90%). Only 8 patients reported some degree of incontinence.

CONCLUSION

The technique of a suprafascial stoma is a simple and safe technique that may help prevent the incidence of stomal complications.

[Urinary diversion in elderly patients]

BACKGROUND

Bladder cancer represents one of the ten most prevalent cancers worldwide. More than 400,000 people worldwide are newly diagnosed every year. Within 2 years after diagnosis, 80% of patients with muscle invasive bladder cancer without treatment die.

METHODS

The aggressive local surgical approach with a cystectomy is the therapy of choice. The median age of patients with de novo bladder cancer is 70 years. Thus bladder cancer is a cancer of the elderly. For demographical reasons, the number of eldery patients undergoing radical cystectomy will rise in the next few years. The type of urinary diversion is a major factor influencing perioperative morbidity and quality of life in these patients. Incontinent urinary diversions are preferentially used in daily practice.

CONCLUSIONS

There are only a few contraindications for orthotopic neobladder; however, age alone is not a contraindication. Patient selection and a nerve sparing approach are crucial in men and women to achieve excellent functional results with orthotopic neobladder in elderly patients.

Long-term follow-up after ileocaecal continent cutaneous urinary diversion (Mainz I pouch): A retrospective study of a monocentric experience

OBJECTIVE

To assess the long-term follow-up after ileocaecal continent cutaneous reservoir (ICCR) and to review the late complications.

PATIENTS AND METHODS

In all, 756 patients underwent an ICCR in our department, with long-term follow-up data available in 50 patients. The inclusion criterion was ICCR regardless of the indication and the exclusion criteria were orthotopic neobladder or other continent urinary diversions not performed with the ileocaecum. Patients were followed to record primary outcomes and late complications. Complications were stratified according to the Clavien-Dindo classification.

RESULTS

The mean patient age was 44 years and pelvic malignancies were the first indication for urinary diversion. The mean (range) follow-up was 19 (9-36) years. A stoma stenosis was the most frequent outlet-related complication requiring re-intervention, followed by ischaemic outlet degeneration, and stoma incontinence. Six renal units (RUs) developed obstruction at the anastomotic site and were managed by open surgery. Three RUs had to be removed due to deterioration. A dederivation was necessary in three patients (6%).

CONCLUSION

The ICCR is a safe and established technique when an orthotopic pouch is impossible. The long-term follow-up shows acceptable complication rates and satisfactory continence conditions. However, large population studies are necessary to confirm this observation.

Pelvic radiation is associated with urinary fistulae repair failure and need for permanent urinary diversion

OBJECTIVE

To review our experience with nonmuscle flap repairs of enterourinary fistulae (EUF) and urinary cutaneous fistulae (UCF). EUF and UCF can be treated either with temporary urinary diversion allowing for healing by secondary intention or primary closure of the defect using an interposing omental, sliding, or muscle flap. Even after successful fistula repair, permanent urinary diversion can be required because of persistent urinary incontinence.

MATERIALS AND METHODS

We reviewed 86 patients who underwent treatment of EUF or UCF at Washington University between the years 1998 and 2013. Of these, 39 patients underwent fistula repair, whereas 47 patients underwent either surgical or nonsurgical urinary diversion. Outcomes measured included postoperative fistula closure, need for permanent urinary diversion, and urinary incontinence.

RESULTS

The mean age in our series was 59 years (21-87 years) at the time of surgery, with median follow-up of 20 months (1-137 months). Among patients who underwent surgical repair, radiation was associated with higher rates of repair failure (P = .0002), postsurgical incontinence (P <.0001), and the need for permanent urinary diversion (P = .0076). At the time of final follow-up, 32 of the 44 radiated patients had required permanent diversion (72%) compared with 3 of the 42 nonradiated patients (7%; P <.0001).

CONCLUSION

Patients who undergo pelvic radiation before EUF and UCF repairs are at higher risk for developing repair failure and postsurgical incontinence. Many patients eventually require permanent urinary diversion. Therefore, EUF and UCF repairs in radiated patients should be undertaken with caution, and patients should be counseled about the possibility of urinary diversion as primary therapy.

[Continent urinary diversion following anterior exenteration]

BACKGROUND

Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir).

RESULTS

Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field.

CONCLUSION

Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Massive stone burden in an ileocecal pouch: A preventable condition?

The challenges of transition from the pediatric to the adult setting have been reported. We describe a case of massive stone burden in the ileocecal pouch of a patient lost to follow-up after his transfer from a pediatric to an adult institution. Although we successfully managed the patient and retrieved the pouch stones without any complications, several surgical complications may occur in a patient with a history of extensive abdominal surgery and bladder exstrophy. This patient's late complication might have been prevented with a more efficient transfer from a pediatric to an adult institution.

EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines

CONTEXT

The European Association of Urology (EAU) guidelines panel on Muscle-invasive and Metastatic bladder cancer (BCa) updates its guidelines yearly. This updated summary provides a synthesis of the 2013 guidelines document, with emphasis on the latest developments.

OBJECTIVE

To provide graded recommendations on the diagnosis and treatment of patients with muscle-invasive BCa (MIBC), linked to a level of evidence.

EVIDENCE ACQUISITION

For each section of the guidelines, comprehensive literature searches covering the past 10 yr in several databases were conducted, scanned, reviewed, and discussed both within the panel and with external experts. The final results are reflected in the recommendations provided.

EVIDENCE SYNTHESIS

Smoking and work-related carcinogens remain the most important risk factors for BCa. Computed tomography (CT) and magnetic resonance imaging can be used for staging, although CT is preferred for pulmonary evaluation. Open radical cystectomy with an extended lymph node dissection (LND) remains the treatment of choice for treatment failures in non-MIBC and T2-T4aN0M0 BCa. For well-informed, well-selected, and compliant patients, however, multimodality treatment could be offered as an alternative, especially if cystectomy is not an option. Comorbidity, not age, should be used when deciding on radical cystectomy. Patients should be encouraged to actively participate in the decision-making process, and a continent urinary diversion should be offered to all patients unless there are specific contraindications. For fit patients, cisplatinum-based neoadjuvant chemotherapy should always be discussed, since it improves overall survival. For patients with metastatic disease, cisplatin-containing combination chemotherapy is recommended. For unfit patients, carboplatin combination chemotherapy or single agents can be used.

CONCLUSIONS

This 2013 EAU Muscle-invasive and Metastatic BCa guidelines updated summary aims to increase the quality of care and outcome for patients with muscle-invasive or metastatic BCa.

PATIENT SUMMARY

In this paper we update the EAU guidelines on Muscle-invasive and Metastatic bladder cancer. We recommend that chemotherapy be administered before radical treatment and that bladder removal be the standard of care for disease confined to the bladder.

Continent urinary diversion

We present a review on the current options for continent urinary diversion and their different indications on the basis of patient selection. In current clinical practice continent urinary diversion is being used world-wide in patients undergoing radical cystectomy and in severe cases of benign bladder pathologies. We also discuss the specific complications of continent urinary diversion and highlight the need to rigorously monitor these patients in the long- term specifically in terms of their renal function and cancer recurrence.

Diagnostic meaning of urodynamic studies in pouch incontinence: results of a small series

INTRODUCTION

To evaluate the meaning of urodynamic parameters in patients with pouch incontinence.

MATERIALS AND METHODS

Thirteen urodynamic studies in patients with an ileal nipple as the efferent segment of an ileocecal pouch or ileum/ileocecal-augmented bladder were performed. The recorded parameters included pouch capacity, leak point pressure/volume, maximum pouch pressure, compliance, static and dynamic closure pressure, and functional length. Three patients suffered from urinary incontinence.

RESULTS

In all cases of incontinent patients, no functional length or static or dynamic closure pressure could be revealed. In 8 of 10 cases of continent patients, a positive functional length as well as static and/or dynamic closure pressure were measured (mean value in continent patients: 15.9 mm, 14.5 cm H2O and 26.5 cm H2O, respectively). In 2 of 3 cases of incontinent patients, the pouch compliance was restricted (21 and 37 ml/cm H2O). The pouch capacity of continent patients was greater than the capacity of incontinent patients (377.4 vs. 185.7 ml).

CONCLUSIONS

Positive functional length, static and dynamic closure pressures, and a high pouch capacity with an unrestricted compliance are predictive for pouch continence. They may individually not determine continence, but combining them can. However, the meaning of urodynamic studies in pouch incontinence is not the same as with the urinary bladder.

Postoperative outcomes after continent versus incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies

OBJECTIVE

To compare outcomes of patients undergoing continent or incontinent urinary diversion after pelvic exenteration for gynecologic malignancies.

METHODS

Data on patients who underwent pelvic exenteration for gynecologic malignancies at The University of Texas MD Anderson Cancer Center between January 1993 and December 2010 were collected. A multivariate logistic regression model was used and statistical significance was P<0.05.

RESULTS

A total of 133 patients were included in this study. The mean age at exenteration was 47.6 (range, 30-73) years in the continent urinary diversion group and 57.2 (range, 27-86) years in the incontinent urinary diversion group (P<0.0001). Forty-six patients (34.6%) had continent urinary diversion, and 87 patients (65.4%) had incontinent urinary diversion. The rates of postoperative complications in patients with continent and incontinent urinary diversion, respectively, were as follows: pyelonephritis, 32.6% versus 37.9% (P=0.58); urinary stone formation, 34.8% versus 2.3% (P<0.001); renal insufficiency, 4.4% versus 14.9% (P=0.09); urostomy stricture, 13.0% versus 1.2% (P=0.007); ureteral (anastomotic) leak, 4.4% versus 6.9% (P=0.71); ureteral (anastomotic) stricture, 13.0% versus 23% (P=0.25); fistula formation, 21.7% versus 19.5% (P=0.82); and reoperation because of complications of urinary diversion, 6.5% versus 2.3% (P=0.34). Among patients with continent urinary diversion, the incidence of incontinence was 28.3%, and 15.2% had difficulty with self-catheterization.

CONCLUSION

There were no differences in postoperative complications between patients with continent and incontinent conduits except that stone formation was more common in patients with continent conduits.

Serous-lined unidirectional valve for construction of continent cutaneous urinary reservoir: the test of time

OBJECTIVE

To assess the long-term outcome of using the serous-lined extramural tunnel technique for construction of continent-cutaneous urinary reservoir in an objective way.

METHODS

Cases that were operated until the end of 2003 and were eligible for evaluation at the time of the study were included. Continence, upper tract status, and complications were the targets of evaluation. Clear definition of continence was used, and biochemical kidney function profile was assessed with calculation of estimated glomerular filtration rate (eGFR) as a measure of the overall renal function in addition to the standard radiological assessment tools. A modified Clavien scale was followed for grading of complications.

RESULTS

After a median of 121.3 months, the final continence rate was 91.1%. Maintained upper tract status was in almost 96.6% of cases and stricture of ureterointestinal anastomosis (UIA) was diagnosed in 3 renal units, and ureteral reflux was diagnosed in 24 renal units. Biochemical kidney function profile showed mean percent reduction of total eGFR to be 14.2%, and 3 patients had ≥50% reduction of total eGFR. On the Clavien scale, low-grade complications (GI-II) occurred in 30 patients (33%) and high-grade complications (≥GIII) occurred in 36 patients (40%). Stoma complications were the most frequent complications. At last follow-up, 42 patients (47%) were free of complications.

CONCLUSION

The serous-lined extramural valve is an efficient technique for maintaining unidirectional flow. Over a decade, good functional outcome of the cutaneous reservoir has been evident. However, with a clear definition of continence and objective assessment of the outcome, at least one third of patients will have high-grade complications, with excellent reintervention outcome maintaining efficacy of the technique.

The efferent segment in continent cutaneous urinary diversion: a comprehensive review of the literature

OBJECTIVE

To critically assess the biophysical properties and current status of outlet formation in heterotopic intestinal urinary diversion. As despite three decades of clinical experience with continent cutaneous urinary diversion through bowel segments, no consensus has been reached for the optimal efferent segment although its function largely determines patient satisfaction.

METHODS

A comprehensive Medline literature search using the Medical Subject Headings database (search terms: continent urinary diversion followed by either efferent segment, nipple, Mitrofanoff, Yang-Monti, Benchekroun, tapered ileum, intussuscepted ileum, Kock pouch, T-valve, or Ghonheim) was conducted to identify all full-length original articles addressing the various principles and techniques of outlet formation as well as their outcomes and complications. Examined series were published in English between 1966 and 2010. All studies were systematically evaluated using a checklist (study design, number of patients, etc.) and rated according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence (LoE).

RESULTS

While there was a continuous flow of publications over the last three decades, the vast majority of studies were retrospective case series with numerous confounding factors and poorly defined, non-standardized outcomes (LoE, 3). Only a few investigations compare different efferent segments (LoE, 2a). No randomized studies exist. The major biophysical principles are based on the use of flap, nipple, and hydraulic valves. Vermiform appendix, intussuscepted ileal nipple, and the Yang-Monti tube are the most popular techniques and have well-established data on outcomes, complications, and failure rates. Artificial sphincter systems and tissue engineering have provided disappointing results thus far. Most reconstructive strategies are subject to a process of on-going improvement.

CONCLUSIONS

The continuous quest for optimization has not led to a single universally applicable efferent segment in continent cutaneous urinary diversion. While all techniques have their unique set of advantages and disadvantages, they will always remain a compromise. Success depends on selecting the optimal strategy for individual patients. A major change in principles in the near future is unlikely.

Evoluting the invaginated--one step closer to the perfect valve? Modified serosal lined tapered ileum (Kälble's procedure) as a continence mechanism for catheterizable pouches

INTRODUCTION

A sufficient and easily catheterizable continence mechanism is essential in continent cutaneous pouches. Kälble embedded a tapered ileum as efferent segment into a serosal lined tunnel formed by an ileal 'U' according to the principle of Abol-Enein and Ghoneim. We report a modified technique applied in a series of 12 patients who had undergone different urinary diversions.

METHODS

All patients received a modified Kälble procedure (first-line urinary diversion, n = 8; revision/undiversion, n = 4) for different forms of continent pouches. To alleviate embedding of the efferent segment, ileal detubularization was performed asymmetrically. Mean follow-up was 9.5 months.

RESULTS

All patients were continent and performed self-catheterization easily. Of 12 patients, 2 underwent endoscopic incision for stomal stenosis 8 and 12 months postoperatively.

CONCLUSIONS

Subject to our short follow-up, Kälble's technique is a promising alternative in patients undergoing a continent cutaneous urinary diversion but offers an inapplicable or missing appendix.

Ileal Conduit and Continent Ileocecal Pouch for Patients Undergoing Pelvic Exenteration: Comparison of Complications and Quality of Life

Objectives:

Creating a continent urinary pouch has become an alternative to the ileal conduit for patients undergoing exenteration for advanced gynecologic malignancies. The objective of this study was to compare clinical outcomes for the 2 methods.

Methods:

In this retrospective study, we compared intraoperative and postoperative complications and quality-of-life scores for the modified ileocecal pouch and the ileal conduit in anterior or total pelvic exenteration.

Results:

In 33 of 100 patients, an ileal pouch (IP) was created; the other 67 were treated by an ileal conduit (IC). Creating an IP prolonged the exenterative procedure by 97 minutes compared to an IC (IC, 453 minutes vs IP, 550 minutes;P= 0.009). Overall complication rates were similar, but patients with an IP had significantly more complications of urinary diversion (48%) than patients with an IC (31%;P= 0.03). Follow-up showed urinary loss and frequency of micturition to be comparable, but in patients with an IP, surgery for stomal complications (n = 2) and treatment of bladderstones were necessary more frequently (n = 3). Quality of life according to the 12-item Short Form Health Survey questionnaire was similar in both groups.

Conclusion:

A continent IP is an alternative to the IC in cases of pelvic exenteration. Early complications are more frequent with an IP than with an IC. The mode of urinary diversion has little influence on the quality of life in patients with advanced genital cancer.

Continent catheterizable umbilical low-pressure intestinal pouch with split ileal end seromuscular anti-reflux technique

BACKGROUND

Cosmesis, better function, and stomal stricture avoidance are important issues in constructing continent urinary abdominal stomas for bladder cancer patients when orthotopic urinary diversion is not feasible. This study aims to evaluate the outcome of continent catheterizable umbilical low-pressure intestinal pouch incorporating a new split ileal end anti-reflux technique.

METHODS

Twenty-three patients underwent a continent umbilical low-pressure intestinal pouch incorporating a new seromuscular antireflux technique (split ileal end) after radical cystectomy when orthotopic reconstruction was not feasible. Mean operative time was 210 min (130 min for radical cystectomy and 80 min for reconstruction of the pouch). The mean follow-up after surgery was 18 mo (range 6-30 mo).

RESULTS

The most common early postoperative complications were urinary leak that occurred in nine patients: seven were conservatively managed and two by re-exploration. Late postoperative complications occurred in eight patients, of whom three developed stomal stenosis and treated successfully with repeated dilatation. Thirteen patients were totally continent, seven were fairly continent, and only two were poorly continent.

CONCLUSIONS

The functional results with this catheterizable umbilical low pressure intestinal pouch incorporating our new anti-reflux technique were satisfactory with better cosmesis.

New Italian guidelines on bladder cancer, based on the World Health Organization 2004 classification

OBJECTIVE To provide evidence-based recommendations on bladder cancer management METHODS A multidisciplinary guideline panel composed of urologists, medical oncologists, radiotherapists, general practitioners, radiologists, epidemiologists and methodologists conducted a structured review of previous reports, searching the Medline database from 1 January 2004 to 31 December 2008. The milestone papers published before January 2004 were accepted for analysis. The level of evidence and the grade of the recommendations were established using the GRADE system. RESULTS In all, 15 806 references were identified, 1940 retrieved, 1712 eliminated (specifying the reason for their elimination) and 971 included in the analysis, as well as 241 milestone reports. A consensus conference held to discuss the discrepancies between the scientific evidence and the clinical practice was then attended by 122 delegates of various specialities. CONCLUSION Recommendations on bladder cancer management are provided.

[Urinary diversions: which one one is right for which patient?]

Standardized operating techniques and surgeons' experiences have contributed to the development of complex urinary diversion systems over the last two decades. Patients' desires and comorbidity risks, such as kidney or bowel dysfunction, as well as their mental and manual abilities need to be taken into account. Careful preoperative decision making is essential if patients are to accept the chosen urinary diversion system and improve their quality of life. Ileal and ileocecal orthotopic neobladders have proven to be effective and comfortable for long-time use, thus stimulating decisions for orthotopic bladder substitution despite the risk of incontinence episodes, especially during the night. Catheterization of continent reservoirs connected to the umbilicus (e.g., ileocecal reservoirs, Mainz pouch I) are widely accepted as an alternative diversion procedure if the urethra and/or sphincter region have to be removed. The patient's desire to avoid a wet stoma and achieve a cosmetically "unchanged" body image is met by these urinary diversion techniques. The surgeon's experience and the patient's mental and general health status must be considered in order to meet the increased complexity of these specific urinary diversions. Nevertheless, elderly patients often tend to prefer an ileal conduit as the easiest solution for urinary diversion. Therefore, even in experienced urological departments, the percentage of patients with orthotopic or self-catheterizable bladder substitution ranges between 30% and 66%, while the ileal conduit is selected in up to 64% of cases after cystectomy. The future of laparoscopic cystectomy has just begun and will affect future techniques of urinary diversion.

Ureteroileocecal appendicostomy based urinary reservoir in irradiated and nonirradiated patients

PURPOSE

The ureteroileocecal appendicostomy reservoir is designed to potentially decrease the morbidity of continent diversion, particularly in previously irradiated patients. We report our experience with this reservoir to compare complications in irradiated and nonirradiated patients.

MATERIALS AND METHODS

The records of 52 consecutive patients who underwent ureteroileocecal appendicostomy diversion between March 2001 and January 2008 were evaluated. Outcomes were analyzed according to whether patients received radiation therapy to the pelvis. Complications were reported as early (within 90 days of surgery) or late.

RESULTS

Overall 29 patients received radiation therapy. The incidence of early complications requiring operative intervention was 14%, including 2 patients (9%) with and 5 (17%) without radiation (p = 0.68). All except 1 reoperation was done to revise the stoma. Early urinary tract infections developed in 17% of nonirradiated and 28% of irradiated patients (p = 0.51). The most common late complication was stomal stenosis requiring dilation on an outpatient basis, which occurred in 21% of patients, including 4 with (17%) and 7 without (24%) radiation (p = 0.74). Late ureteral complications requiring intervention were reported in 15% of renal units, including 2 of 44 without (5%) and 6 of 56 with (11%) radiation (p = 0.21).

CONCLUSIONS

Ureteroileocecal appendicostomy is a safe, effective technique for continent cutaneous urinary diversion in heavily irradiated patients. Complication rates did not significantly differ between irradiated and nonirradiated patients, and appear improved compared to those in previous reports.